02/28/2018. To reduce morbidity, mortality and treatment loss associated with chronic volume overload in hemodialysis patients

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1 Lisa Koester Renal Nurse Practitioner Washington University School of Medicine St. Louis, MO To reduce morbidity, mortality and treatment loss associated with chronic volume overload in hemodialysis patients 2 A patient arrives for dialysis with excess fluid to remove.. What happens? A (sometimes ugly) confrontation occurs with: "... you have not adhered to your fluid restriction..." With lots of fluid to remove, a high ultrafiltration rate (UFR) is required and set. 1

2 Mr. Jones Reply: I can take it off. I have done it before Staff: Patient is set for goal and then. My Reply: Kalantar-Zadeh, et al. Circulation. 2009,119: Patient goes "flat" halfway through Urgent "resuscitation" starts, with normal saline (of course) But wait: isn't dialysis meant to be removing excess salt and water? 2

3 After loading up with salt and water (saline), more fluid is taken off, and fast, for time is now short Cramps are occurring, hypotension and overall feeling poorly Goal: Did get volume off patient? Did we succeed? What happens next Patient leaves THIRSTY so they drink! So would you you would have to! Your brain stem would insist on it! And so this "noncompliant" patient complies with the primal survival drive of thirst, and drinks! This blog post was made by Dr. John Agar on December 17th, In 2 days time (or 3, at the staff convenient weekend), the patient returns, finally revitalized by fluid, but volume overloaded AGAIN. More angry berating ensues "You must be more compliant, you are killing yourself... No... we are the ones doing the killing. 3

4 Mistake #1: The dialysis session is too short. A longer session allows the removal of the same volume over a longer time at a lower UFR This blog post was made by Dr. John Agar on December 17th, Berating a patient for "non compliance" is (a) cruel and (b) an abuse of a patient for our own mistake: 'excess fluid to remove' is fluid that we forced the patient to drink an instinct we ignited through far too rapid a contraction of blood volume abetted by further salt loading during the inevitable circulatory resuscitation This blog post was made by Dr. John Agar on December 17th, It isn't the patient who "doesn't get it." We are the ones that don't get it! This blog post was made by Dr. John Agar on December 17th,

5 What is the patient s weight? Remember.03% vs.05% Fluid Removal Example: DW 70 KG.03% is 2.1 kg removal.05% 3.5 kg removal TOO MUCH Source: Chazot & Jean,

6 Ball, L 2014 Network 13 Ball, L 2014 Network 13 Dyspnea lead to pulmonary complications Kraemer M, Rode C, Wizemann V. KI 2006; 69;

7 Edema facilitates skin breakdown Kraemer M, Rode C, Wizemann V. DeteKI 2006; 69; Repeated Heart Ischemia Myocardial Stunning Ischemia Brain, gut, LVH, Heart, CHF Death MD RD PCT SW RN 7

8 Witness patients weigh in and out Assess at your patient look at them Breathing Hard Fluid edema evident (hands, feet, face) Vital Signs Look at flow sheet trend? Does it make sense? Hospitalizations? Is DW correct? Talk with your patient How did your last treatment go? How did you feel in between treatments? Talk with your co workers Notify RN of any patients that has gained > 5% of DW before starting treatment Notify RN if patient is above DW post treatment Screen shot 24 8

9 Thomson et al Reduction of BP to hypotensive levels during ultrafiltration and unassociated with other obvious causes Henderson et al Weight obtained at the conclusion of a regular dialysis treatment below which the patient more often than not will become symptomatic and go into shock. Thomson GE, et al: Arch Intern Med 120: , Charra et al That body weight at the end of dialysis at which the patient can remain normotensive until the next dialysis despite the retention of fluid and ideally without the use of antihypertensive medications 2009 Sinha and Agarwal The lowest tolerated post dialysis weight achieved via gradual change in post dialysis weight at which there are minimal signs and symptoms of hypovolemia or hypervolemia Charra B, et al: NDT 11[Suppl 2]: 16 19, 1996 Sinha AD, Agarwal R: Semin Dial 22: , 2009 Is what the patient s weight would be with no extra fluid and with a normal blood pressure MD/NP prescribes a DW and this number is then used to decide how much fluid weight is to be removed during the treatment. At the end of HD w/ normal BP, no edema & no SOB 9

10 Hospital Stay or illness with loss of appetite, diarrhea, or vomiting can cause drop in DW Holidays often cause increases in DW More urine production Pt may be exercising or lifting weights to build muscle Clothes Scale Accuracy Medications Diet AT DRY WEIGHT Normal BP (varies) No edema No shortness of breath Stable overall ABOVE DRY WEIGHT HTN Evidence of fluid Edema SOB Feeling bloated or full Below Dry Weight Hypotension Headache Elevated HR Cramps Nausea/vomiting Dizziness Required intervention(saline) 10

11 Too Dry Classic symptoms drop in blood pressure (BP) feeling faint cramping Blood pressure drop results in ischemia BP is too low to deliver oxygen to the cells 31 Dizziness, seizures Headache, stroke Chest pain, MI Nausea, vomiting, diarrhea Muscle cramping Possible long term affects Damage to vital organs, including heart and brain 32 Excess sodium exposure (intradialytic and interdialytic) is a primary cause of excessive interdialytic fluid weight gain and poor control of sodium and volume mediated hypertension 11

12 Dialysate sodium and Sodium Profiling Greater than 138 meq/l dialysate sodium represents excessive exposure to sodium Can lead to increased thirst, higher IDWG, worsening hypertension and left ventricular hypertrophy KDOQI clinical practice guidelines state that use of high dialysate sodium and sodium profiling should be avoided More hypotension during tx Na loading during tx (NS, dialysate, Na modeling) More stable BP and lower need for NS No Na loading during tx (i.e. dialysate Na is the same as pre-tx serum NA Need for higher UFR SODIUM LOADING Serum Na increases during tx Lower UFR NO SODIUM LOADING Serum Na the same post tx as pre tx Increased fluid weight gains, and elevated BP Thirst between treatments Less fluid weight gain between tx Less thirst between tx Davita RD Meeting If the BP falls give salt: old and wrong Limiting sodium intake is not just a dietary issue The patient is not the only one responsible for limiting sodium load Any action that adds sodium to the patient s intravascular system has the potential to increase thirst and fluid weight gains *Broth given for hypotension contains as much as mg sodium (1/3 to 1/2 of daily recommendation 12

13 Maximum UF Rate Ultrafiltration rate above 15 ml/kg/hr: recommended 10 13ml/kg/hr Higher rate of intradialytic hypotension Unstable dialysis sessions Higher mortality Intradialytic ischemic episodes Increase treatment time when needed to Decrease intradialytic and post dialysis hypotension Optimize blood pressure control Frequency Duration ICNHD HHD SDHD 13

14 Intake of fluids is related to: Physical needs Habits Customs Social rituals Disease *CONTROL Alleviate dry mouth Match ingestion of food Enjoy the taste or experience of liquid Take prescribe medications Seasons of the year affect consumption Regulatory reaction to thirst/physical deficit of fluid Motivational and cognitive processes Dialysis pts are drinking in response to osmometric thirst and sodium intake is important part of the behavior 14

15 Controlling fluid intake is essential for proper self care. However, clinical experience has shown that, compared to attendance to HD sessions or fulfillment of drug prescription, this is the factor with the highest level of non compliance Carmelo Iborra Molto et al. Adherence to fluid restriction, Nefrologia 2012;32(4): Restrictions for Anuric Patient:.5.9 liters/day (make 1 liter/day) Normal Hydration is 2 liters between HD sessions to prevent intradialysis events by 75% and the risk of mortality by 50% Carmelo Iborra Molto et al. Adherence to fluid restriction, Nefrologia 2012;32(4): Ultrafiltration during dialysis is the result of the TMP (transmembrane pressure) in the dialyzer which removes plasma water from the blood compartment of the dialyzer to the dialysate compartment. If the rate of removal exceeds the rate of plasma refill then hypovolemia and hypotension occur. 15

16 Interval UFR profiles seem to optimize plasma refill and allow UF goals to be reached with minimum to no intradialytic complications Plasma volume (Vascular Space) Extravascular ECV ICV 28 L ECV Kg <1.5 L/hr No Hypotension 11 L + 3 Kg 1.5 L/ hr 70Kg patient with normal fluid distribution, gains 4 kg in between dialyses. Dialysis time 3 hours, UFR= 1.33 L/hr. Slower refill rate than of 1.5L/hr Lower risk of hypotension Plasma volume (Vascular Space) Extravascular ECV ICV 28 L 11L + 6Kg 1.5 L/ hr ECV Kg UFR 2.6L/hr PV depletion and hypotension 70Kg patient with normal fluid distribution, gains 8 kg in between dialyses. Dialysis time 3 hours, UFR= 2.6 L/hr. Faster than the refill rate of 1.5L/hr Consequently increased risk of hypotension 16

17 Profile One Provides relatively high level UF for almost half the run, then begins gradually decreasing until the end of the run Profile Two Gives a gradual decline in removal, but again, starting with aggressive UF in the early part of dialysis. These work well with a patient with high weight gains, possibly symptomatic ( SOB, HTN) and with a tolerance for rapid fluid removal Profile THREE Moderate UF throughout 2/3 rd, followed by a more dramatic decrease in last portion. This would work well with the patient who becomes hypotensive in the last hour or comes off the machine with a low BP 17

18 Profile FOUR Starts low UF &moves into series of decreasing peaks & valleys for the first 2/3rds. This profile will facilitate the patient with poor vascular response who drops BP early and needs time for plasma refill. This patient would probably benefit from sodium variation also. There are a few basic rules to apply when evaluating a patient that will help to develop an individual fluid removal plan Dry weight evaluation Physical Assessment All patients do not need modeling and/or profiling Some may need a combination of both Others may use only UF profile or only NA modeling Low serum albumin levels Poor Heparinization Increased HCT (>36%) Poor blood flow rates Multiple Alarms Failing Vascular Access 18

19 By designing an adequate treatment program and refining ultrafiltration, fluid overload is a preventable and correctable risk factor in dialysed patients Canaud B & Lertdumrongluk P Probing 'dry weight' in HD pts: 'back to the future'. NDT 2012 Jun;27(6): MD RD PCT SW RN 19